Cerebral Spinal Fluid Penetration of Tigecycline in a Patient with Acinetobacter baumannii Cerebritis (March).

Ann Pharmacother. 2010 Feb 23;

Authors: Ray L, Levasseur K, Nicolau DP, Scheetz MH

OBJECTIVE: To describe cerebral spinal fluid (CSF) penetration of tigecycline. CASE SUMMARY: A 38-year-old woman experienced a right internal carotid artery dissection and right anterior and middle cerebral artery strokes due to unknown causes and subsequently developed vasogenic edema requiring right hemicraniectomy. Her postoperative course was complicated by multiple infections, and she developed multidrug, carbapenem-resistant Acinetobacter baumannii cerebritis. She was treated with a prolonged course of multiple antibiotics, including 18 days of therapy with tigecycline. Time-paired serum and CSF samples were obtained, and tigecycline concentrations were analyzed by high-performance liquid chromatography. We report serial, steady-state, serum, and CSF concentrations of tigecycline when administered in the Food and Drug Administration-approved dose of 50 mg every 12 hours. CSF concentrations remained relatively stable, suggesting that tigecycline did not accumulate in the CSF, at least in our patient. Tigecycline concentrations in the CSF were between 0.035 and 0.048 mg/L, while corresponding serum concentrations were 0.097-0.566 mg/L. The calculated tigecycline penetration ratio in this patient ranged from 0% to 52%, depending on the calculation methodology utilized. DISCUSSION: Concentrations, regardless of sample timing relative to dose, remained relatively stable in the CSF of our patient. The pharmacodynamic profile of tigecycline is not completely elucidated; however, it is presumed that the drug must be at the site of infection for efficacy. Our patient never obtained tigecycline concentrations in excess of the minimum inhibitory concentration for A. baumannii in either the serum or the CSF. CONCLUSIONS: Our patient experienced low CSF tigecycline concentrations and failed to achieve a clinical response while on therapy. CSF drug disposition of tigecycline requires further systematic study to fully elucidate the pharmacokinetic profile. Reduced CSF concentrations urge caution in the treatment of cerebritis with standard dosing of tigecycline.

PMID: 20179255 [PubMed - as supplied by publisher]

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Surgical Masks for Protection of Health Care Personnel against Pandemic Novel Swine-Origin Influenza A (H1N1)-2009: Results from an Observational Study.

Clin Infect Dis. 2010 Feb 23;

Authors: Ang B, Poh BF, Win MK, Chow A

There is ongoing debate about the efficacy of surgical masks versus N95 respirators for protection against pandemic novel swine-origin influenza A (H1N1)-2009. Our hospital, which is designated to manage outbreaks of emerging infection, has robust surveillance systems to detect infection in staff. The incidence of pandemic H1N1-2009 remained low in staff with use of surgical masks.

PMID: 20178418 [PubMed - as supplied by publisher]

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Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction.

Circ Cardiovasc Qual Outcomes. 2010 Feb 23;

Authors: Glickman SW, Boulding W, Manary M, Staelin R, Roe MT, Wolosin RJ, Ohman EM, Peterson ED, Schulman KA

Background Hospitals use patient satisfaction surveys to assess their quality of care. A key question is whether these data provide valid information about the medically related quality of hospital care. The objective of this study was to determine whether patient satisfaction is associated with adherence to practice guidelines and outcomes for acute myocardial infarction and to identify the key drivers of patient satisfaction. Methods and Results We examined clinical data on 6467 patients with acute myocardial infarction treated at 25 US hospitals participating in the CRUSADE initiative from 2001 to 2006. Press Ganey patient satisfaction surveys for cardiac admissions were also available from 3562 patients treated at these same 25 centers over this period. Patient satisfaction was positively correlated with 13 of 14 acute myocardial infarction performance measures. After controlling for a hospital's overall guideline adherence score, higher patient satisfaction scores were associated with lower risk-adjusted inpatient mortality (P=0.025). One-quartile changes in both patient satisfaction and guideline adherence scores produced similar changes in predicted survival. For example, a 1-quartile change (75th to 100th) in either the patient satisfaction score or the guideline adherence score yielded the same change in predicted survival (odds ratio, 1.24; 95% CI, 1.02 to 1.49; and odds ratio, 1.24; 95% CI, 1.08 to 1.41, respectively). Satisfaction with nursing care was the most important determinant of overall patient satisfaction (P<0.001). Conclusions Higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients are good discriminators of the type of care they receive. Thus, patients' satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care.

PMID: 20179265 [PubMed - as supplied by publisher]

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Proposed changes to management of lower respiratory tract infections in response to the Clostridium difficile epidemic.

J Antimicrob Chemother. 2010 Feb 23;

Authors: Chalmers JD, Al-Khairalla M, Short PM, Fardon TC, Winter JH

Clostridium difficile infection (CDI) remains a major healthcare problem associated with antibiotic use in hospitals. Recent years have seen a dramatic increase in the incidence of CDI in the UK and internationally. Lower respiratory tract infections (LRTIs) are the leading indication for antibiotic prescription in hospitals and are therefore a critical battleground in the fight against inappropriate antibiotic use and healthcare-associated infections. This article reviews the evidence for interventions to reduce CDI in hospitalized patients with LRTIs. Reducing prescriptions of cephalosporins and fluoroquinolones in favour of penicillin-based regimens and increased use of tetracyclines have been proposed. Expanding outpatient management of LRTIs and reducing length of hospital stay will limit patient exposure to the healthcare environment in which C. difficile is most easily acquired. Intravenous (iv) broad-spectrum antibiotics are often prescribed when narrower spectrum, oral antimicrobials would be equally effective and, in a proportion of patients, antibiotic therapy is used unnecessarily. Shorter antibiotic regimes may be as effective as prolonged therapy and reduce antibiotic-related complications. Early switch from iv to oral therapy allows simpler antibiotic regimens and facilitates early discharge from hospital. Simple improvements in the management of LRTIs have the potential to reduce the incidence of healthcare-associated infections.

PMID: 20179023 [PubMed - as supplied by publisher]

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Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study.

Crit Care. 2010 Feb 24;14(1):R25

Authors: Nichol A, Egi M, Pettila V, Bellomo R, French C, Hart G, Davies A, Stachowski E, Reade MC, Bailey M, Cooper DJ

ABSTRACT: INTRODUCTION: Higher lactate concentrations within the normal reference range ("relative hyperlactatemia") are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death. METHODS: Retrospective observational study of prospectively obtained intensive care database of 7155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission (LacADM), maximal (LacMAX) and time-weighted (LacTW) lactate levels and hospital outcome in all patients and in those patients whose LacADM (n=3964), LacMAX (n=2511) and LacTW (n=4584) lactate was under 2 mmol.L-1 (relative hyperlactatemia). RESULTS: We obtained 172,723 lactate measurements. Higher LacADM and LacTW concentration within the reference range was independently associated with increased hospital mortality (LacADM: odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3-3.5, P=0.01; LacTW OR 3.7, 95% CI 1.9-7.00, P<0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate never exceeded 2 mmol.L-1, higher LacTW remained strongly associated with higher hospital mortality (LacTW OR 4.8, 95% CI 1.8-12.4, P<0.001). CONCLUSIONS: In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations >0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.

PMID: 20181242 [PubMed - as supplied by publisher]

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Related Articles

Clinical Trial: High-dose furosemide plus small-volume hypertonic saline solutions vs. repeated paracentesis as treatment of refractory ascites.

Aliment Pharmacol Ther. 2009 Aug;30(3):227-35

Authors: Licata G, Tuttolomondo A, Licata A, Parrinello G, Di Raimondo D, Di Sciacca R, Cammà C, Craxì A, Paterna S, Pinto A

BACKGROUND: In patients with cirrhosis, ascites is defined as refractory when it cannot be mobilized or recurs early in standard diuretic therapy. AIM: To compare the safety and efficacy of intravenous high-dose furosemide + hypertonic saline solutions (HSS) with repeated paracentesis in patients with cirrhosis and refractory ascites. PATIENTS AND METHODS: Eighty-four subjects (59/25 M/F) with cirrhosis, mostly of viral aetiology, admitted for refractory ascites, were randomly assigned to receive furosemide (250-1000 mg/bid i.v.) plus HSS (150 mL H(2)O with NaCl 1.4-4.6% or 239-187 mEq/L) (60 patients, Group A) or to repeated paracentesis and a standard diuretic schedule (24 patients, Group B). RESULTS: During hospitalization, Group A patients had more diuresis (1605 +/- 131 mL vs. 532 +/- 124 mL than Group B patients; P < 0.001) and a greater loss of weight at discharge (-8.8 +/- 4.8 kg vs. -4.5 +/- 3.8 kg, P < 0.00). Control of ascites, pleural effusions and/or leg oedema was deemed significantly better in Group A. CONCLUSIONS: This randomized pilot study suggests that HHS plus high-dose furosemide is a safe and effective alternative to repeated paracentesis when treating hospitalized patients with cirrhosis and refractory ascites. Larger studies will be needed to evaluate long-term outcomes such as readmission and mortality.

PMID: 19438847 [PubMed - indexed for MEDLINE]

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New developments in the preoperative evaluation and perioperative management of coronary artery disease in patients undergoing vascular surgery.

J Vasc Surg. 2010 Jan;51(1):242-51

Authors: Bauer SM, Cayne NS, Veith FJ

BACKGROUND: Preoperative evaluation and perioperative management of cardiac disease in patients undergoing vascular surgery (VS) is important for patients and vascular surgeons. Recent evidence has emerged that has allowed us to develop contemporary paradigms for evaluating and managing coronary artery disease in VS patients perioperatively. METHODS: The utility of stress testing, the role of preoperative coronary revascularization, the optimal use of beta-blockers and statins, and the role of antiplatelet therapy in VS patients were reviewed in the literature. RESULTS: The revised Lee cardiac risk index, based on the number of risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes mellitus, renal failure, hypertension, and age >75) quantitates cardiac risk. Stress testing is not predictive of myocardial ischemia/infarction (MI) or death and is only recommended in patients with unstable angina or an active arrhythmia. Stress testing for patients with 0 to 2 risk factors delays VS up to 3 weeks. In high-risk patients (>or=3 risk factors), it helps to identify patients who may develop myocardial ischemia and would benefit from a 30-day period to optimize medical therapy before VS. Stress testing and coronary catheterization do not predict which coronary artery to revascularize to prevent MI or death. Revascularization does not decrease MI or death rates at 1 month or 6 years. Although beta-blocker treatment decreases cardiac risk with VS, timing and dosage (titration) influence outcomes, improper usage may increase stroke and death rate, and not all VS patients should be taking these drugs. Patients with >or=1 risk factor should be considered to begin a low dose beta-blocker 1 month before VS. Preoperative statin use sharply decreases MI, stroke, and death perioperatively and long-term postoperatively. CONCLUSION: Routine stress testing should not be performed before VS. The Lee index should be used to stratify risk in patients undergoing VS. Patients with >or=3 risk factors or active cardiac conditions should undergo stress testing, if VS can be delayed. All VS patients, except those with 0 risk factors, should be considered for a beta-blocker (bisoprolol, 2.5-5 mg/d started 1 month before VS, titrated to a pulse <70 beats/min and a systolic blood pressure >or=120 mm Hg). Intermediate risk factors may not require aggressive heart rate control but simply maintenance on a low-dose beta-blocker. Statins should be started (ideally 30 days) before all VS using long-acting formulations such as fluvastatin (80 mg/d) for patients unable to take oral medication.

PMID: 19954922 [PubMed - indexed for MEDLINE]

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Management of bleeding and of invasive procedures in patients with platelet disorders and/or thrombocytopenia: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET).

Thromb Res. 2009 Nov;124(5):e13-8

Authors: Tosetto A, Balduini CL, Cattaneo M, De Candia E, Mariani G, Molinari AC, Rossi E, Siragusa S,

The optimal management of bleeding or its prophylaxis in patients with disorders of platelet count or function is controversial. The bleeding diathesis of these patients is usually mild to moderate: therefore, transfusion of platelet concentrates may be inappropriate, as potential adverse effects might outweigh its benefit. The availability of several anti-hemorrhagic drugs further compounds this problem, mainly because the efficacy/suitability of the various treatment options in different clinical manifestations is not well defined. In these guidelines, promoted by the Italian Society for Studies on Haemostasis and Thrombosis (Società Italiana per lo Studio dell'Emostasi e della Trombosi [SISET]), we aim at offering the best available evidence to help the physicians involved in the management of patients with disorders of platelet count or function. Literature review and appraisal of available evidence are discussed for different clinical settings and for different available treatments, including platelet concentrates (PC), recombinant activated factor VII, desmopressin, antifibrinolytics, aprotinin and local hemostatic agents.

PMID: 19631969 [PubMed - indexed for MEDLINE]

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Treatment of venous thromboembolism in patients with cancer: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET).

Thromb Res. 2009 Nov;124(5):e32-40

Authors: Imberti D, Di Nisio M, Donati MB, Falanga A, Ghirarduzzi A, Guarneri D, Piovella F, Santoro RC, Baldini E, Zampogna S,

BACKGROUND: The treatment of venous thromboembolism (VTE) in cancer patients remains controversial. PURPOSE: The Italian Society for Thrombosis and Haemostasis (SISET) commissioned a project to develop clinical practice guidelines for the therapy of VTE in patients with malignancies. METHODS: Key questions about the treatment of VTE in patients with malignancies were formulated by a multidisciplinary working group consisting of experts in clinical medicine and research. After a systematic review and discussion of the literature, recommendations were formulated and graded according to the supporting evidence. For those questions for which the literature search did not yield any definitive answer (absence of evidence evidence of low quality, and contradictory evidence), a formal consensus method was used to issue clinical recommendations. RESULTS: The results of the available literature on VTE treatment in cancer patients were reviewed and clinical recommendations were drafted. CONCLUSION: We describe the results of a systematic literature review and an explicit approach to consensus techniques which resulted in recommendations for the key therapeutic issues in cancer patients with VTE.

PMID: 19744700 [PubMed - indexed for MEDLINE]

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Medication errors: problems and recommendations from a consensus meeting.

Br J Clin Pharmacol. 2009 Jun;67(6):592-8

Authors: , Agrawal A, Aronson JK, Britten N, Ferner RE, de Smet PA, Fialová D, Fitzgerald RJ, Liki? R, Maxwell SR, Meyboom RH, Minuz P, Onder G, Schachter M, Velo G

Here we discuss 15 recommendations for reducing the risks of medication errors: 1. Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. 2. Provision of opportunities for students to practise skills that help to reduce errors. 3. Education of students about common types of medication errors and how to avoid them. 4. Education of prescribers in taking accurate drug histories. 5. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. 6. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. 7. Comprehensive assessment of elderly patients for declining function. 8. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. 9. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. 10. More involvement of pharmacists in clinical practice. 11. Introduction of integrated prescription forms and national implementation in individual countries. 12. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. 13. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. 14. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. 15. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

PMID: 19594525 [PubMed - indexed for MEDLINE]

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Variation in physician deep vein thrombosis prophylaxis attitudes and practices at an academic tertiary care center.

J Thromb Thrombolysis. 2010 Feb 20;

Authors: Galbraith EM, Vautaw BM, Grzybowski M, Henke PK, Wakefield TW, Froehlich JB

Background Deep vein thrombosis (DVT) remains a major cause of in-hospital morbidity and mortality. Effective DVT prophylaxis is available but underutilized. We sought to describe physician understanding of DVT epidemiology and prophylaxis practices. Methods All medical and surgical residents, and hospitalist attendings were invited to participate in an on-line survey. Physicians were queried about DVT epidemiology, risk factors, prophylaxis practices, and complications. Means and standard deviations were calculated for ordinal responses. chi(2) was used for dichotomous variables. Results Of 281 doctors emailed, 69/160 (43%) medical residents, 26/72 (36%) surgical residents, and 21/49 (43%) hospitalist attendings participated. All three overestimated DVT incidence and morbidity. Surgical residents listed paralysis as high risk and minor surgery as a low/no risk factor. Medical residents thought heart failure and varicose veins were low/no risk for developing DVT. Regarding prophylaxis, surgical residents did not identify ambulation as a prophylactic measure, and were more likely to use SCDs, compression stockings, and enoxaparin, while medical residents and hospitalist attendings prescribed unfractionated heparin most frequently. Medical residents reported that they would hold anticoagulants for comorbidities most frequently, but all 3 groups agreed that anticoagulant prophylaxis would not significantly increase bleeding risks. Conclusions Perceptions of DVT risk factors and prophylaxis practices vary by both physician specialty and attending/resident status. Prophylaxis practice differences may result from these perceptions.

PMID: 20174856 [PubMed - as supplied by publisher]

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Comanagement of hospitalized surgical patients by medicine physicians in the United States.

Arch Intern Med. 2010 Feb 22;170(4):363-8

Authors: Sharma G, Kuo YF, Freeman J, Zhang DD, Goodwin JS

BACKGROUND: Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States. METHODS: We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized. RESULTS: Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians. CONCLUSIONS: Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

PMID: 20177040 [PubMed - in process]

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Hospital cost of care, quality of care, and readmission rates: penny wise and pound foolish?

Arch Intern Med. 2010 Feb 22;170(4):340-6

Authors: Chen LM, Jha AK, Guterman S, Ridgway AB, Orav EJ, Epstein AM

BACKGROUND: Hospitals face increasing pressure to lower cost of care while improving quality of care. It is unclear if efforts to reduce hospital cost of care will adversely affect quality of care or increase downstream inpatient cost of care. METHODS: We conducted an observational cross-sectional study of US hospitals discharging Medicare patients for congestive heart failure (CHF) or pneumonia in 2006. For each condition, we examined the association between hospital cost of care and the following variables: process quality of care, 30-day mortality rates, readmission rates, and 6-month inpatient cost of care. RESULTS: Compared with hospitals in the lowest-cost quartile for CHF care, hospitals in the highest-cost quartile had higher quality-of-care scores (89.9% vs 85.5%) and lower mortality for CHF (9.8% vs 10.8%) (P < .001 for both). For pneumonia, the converse was true. Compared with low-cost hospitals, high-cost hospitals had lower quality-of-care scores (85.7% vs 86.6%, P = .002) and higher mortality for pneumonia (11.7% vs 10.9%, P < .001). Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals (24.7% vs 22.0%, P < .001 for CHF and 17.9% vs 17.3%, P = .20 for pneumonia). Nevertheless, patients initially seen in low-cost hospitals incurred lower 6-month inpatient cost of care compared with patients initially seen in hospitals with the highest cost of care ($12 715 vs $18 411 for CHF and $10 143 vs $15 138 for pneumonia, P < .001 for both). CONCLUSIONS: The associations are inconsistent between hospitals' cost of care and quality of care and between hospitals' cost of care and mortality rates. Most evidence did not support the "penny wise and pound foolish" hypothesis that low-cost hospitals discharge patients earlier but have higher readmission rates and greater downstream inpatient cost of care.

PMID: 20177036 [PubMed - in process]

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Pneumothorax Following Thoracentesis: A Systematic Review and Meta-analysis.

Arch Intern Med. 2010 Feb 22;170(4):332-9

Authors: Gordon CE, Feller-Kopman D, Balk EM, Smetana GW

BACKGROUND: Little is known about the factors related to the development of pneumothorax following thoracentesis. We aimed to determine the mean pneumothorax rate following thoracentesis and to identify risk factors for pneumothorax through a systematic review and meta-analysis. METHODS: We reviewed MEDLINE-indexed studies from January 1, 1966, through April 1, 2009, and included studies of any design with at least 10 patients that reported the pneumothorax rate following thoracentesis. Two investigators independently extracted data on the pneumothorax rate, risk factors for pneumothorax, and study methodological quality. RESULTS: Twenty-four studies reported pneumothorax rates following 6605 thoracenteses. The overall pneumothorax rate was 6.0% (95% confidence interval [CI], 4.6%-7.8%), and 34.1% of pneumothoraces required chest tube insertion. Ultrasonography use was associated with significantly lower risk of pneumothorax (odds ratio [OR], 0.3; 95% CI, 0.2-0.7). Lower pneumothorax rates were observed with experienced operators (3.9% vs 8.5%, P = .04), but this was nonsignificant within studies directly comparing this factor (OR, 0.7; 95% CI, 0.2-2.3). Pneumothorax was more likely following therapeutic thoracentesis (OR, 2.6; 95% CI, 1.8-3.8), in conjunction with periprocedural symptoms (OR, 26.6; 95% CI, 2.7-262.5), and in association with, although nonsignificantly, mechanical ventilation (OR, 4.0; 95% CI, 0.95-16.8). Two or more needle passes conferred a nonsignificant increased risk of pneumothorax (OR, 2.5; 95% CI, 0.3-20.1). CONCLUSIONS: Iatrogenic pneumothorax is a common complication of thoracentesis and frequently requires chest tube insertion. Real-time ultrasonography use is a modifiable factor that reduces the pneumothorax rate. Performance of thoracentesis for therapeutic purposes and in patients undergoing mechanical ventilation confers a higher likelihood of pneumothorax. Experienced operators may have lower pneumothorax rates. Patient safety may be improved by changes in clinical practice in accord with these findings.

PMID: 20177035 [PubMed - in process]

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Hypoglycemia and Outcome in Critically Ill Patients.

Mayo Clin Proc. 2010 Feb 22;

Authors: Moritoki E, Bellomo R, Stachowski E, French CJ, Hart GK, Taori G, Hegarty C, Bailey M

OBJECTIVE: To determine whether mild or moderate hypoglycemia that occurs in critically ill patients is independently associated with an increased risk of death. PATIENTS AND METHODS: Of patients admitted to 2 hospital intensive care units (ICUs) in Melbourne and Sydney, Australia, from January 1, 2000, to October 14, 2004, we analyzed all those who had at least 1 episode of hypoglycemia (glucose concentration, <81 mg/dL). The independent association between hypoglycemia and outcome was statistically assessed. RESULTS: Of 4946 patients admitted to the ICUs, a cohort of 1109 had at least 1 episode of hypoglycemia (blood glucose level, <81 mg/dL). Of these 1109 patients (22.4% of all admissions to the intensive care unit), hospital mortality was 36.6% compared with 19.7% in the 3837 nonhypoglycemic control patients (P<.001). Even patients with a minimum blood glucose concentration between 72 and 81 mg/dL had a greater unadjusted mortality rate than did control patients (25.9% vs 19.7%; unadjusted odds ratio, 1.42; 95% confidence interval, 1.12-1.80; P=.004.) Mortality increased significantly with increasing severity of hypoglycemia (P<.001). After adjustment for insulin therapy, hypoglycemia was independently associated with increased risk of death, cardiovascular death, and death due to infectious disease. CONCLUSION: In critically ill patients, an association exists between even mild or moderate hypoglycemia and mortality. Even after adjustment for insulin therapy or timing of hypoglycemic episode, the more severe the hypoglycemia, the greater the risk of death.

PMID: 20176928 [PubMed - as supplied by publisher]

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